The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)
Has a history of alcohol abuse
Bathes three to four times a week
Has a history of diabetes mellitus
Becomes diaphoretic on warm days
is prescribed antidepressant
Has a history of a cerebrovascular accident CVA
Correct Answer : A,C,D,F
A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.
B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.
C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.
D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.
E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.
F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Use cool or tepid water: Applying cool or tepid water to the body, such as through a cool bath or damp cloth, can help reduce body temperature.
B. Avoid alcohol: Alcohol can contribute to dehydration, which increases the risk of hyperthermia. It's important to encourage the client to avoid alcoholic beverages during hot weather.
C. Minimize exertion: Exertion in high temperatures can lead to an increase in body heat. Advising the elderly client to minimize physical exertion during hot weather helps prevent overheating.
D. Wear cool clothing such as silk or polyester: Light and breathable fabrics, such as silk or polyester, promote better air circulation and help the body stay cool.
E. Drink plenty of fluids: Staying hydrated is crucial in preventing hyperthermia. Encourage the client to drink plenty of fluids, particularly water, to maintain proper hydration levels.
Correct Answer is C
Explanation
A. Decreased serum albumin levels can be an indicator of protein malnutrition, but it may not reflect overall nutritional status comprehensively. It is more specific to protein status.
B. Decreased vitamin D levels are related to a specific nutrient (vitamin D) and may indicate a deficiency in that vitamin, but it doesn't provide a broad assessment of overall nutritional status.
C. Unintentional weight loss is a key indicator of potential nutritional deficit.
Unintentional weight loss is a significant concern, especially in older adults, as it can be indicative of various underlying health issues, including malnutrition. It is a more general indicator of overall nutritional status.
D. Anorexia lasting more than 24 hours may contribute to weight loss, but it is a symptom rather than a direct measure of nutritional status. Unintentional weight loss encompasses a broader view of changes in body weight that may signal nutritional deficits.
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